Holiday Eating

Jean Fain, LICSW, MSW Reprinted with permission from The Huffington Post. 

Sadly, too many party goers are more focused on their ever-spreading mid section than spreading holiday cheer. If all you really want for Christmas is the secret to overcoming overeating, you're in luck. I recently discussed preventing seasonal weight gain with one of the leading experts on feeding our families and ourselves: Ellyn Satter. Before I devoured Satter's writing on food and family, I gobbled up her definition on normal eating. Even if you're familiar with Satter's un-American definition, it's worth rereading. 

As a psychotherapist and dietitian, Satter really understands why the great majority of us feel compelled to eat like there's no tomorrow. So when it came time for my annual interview on seasonal eating concerns, I could think of no better subject than the author of Secrets of Feeding a Healthy Family. What follows are questions and answers from my recent conversation with Ellyn Satter. 

Fain. How would you describe normal holiday eating?

Satter. Normal eating is all about trusting yourself to eat in a way that is right for you. The trouble most people have with holiday eating is they get caught up in what they should and shouldn't eat. They're anxious and ambivalent about eating. They might try to resist at holiday parties, but the table is laden with oh-so-appealing "forbidden foods," and they throw away all control and overdo it. Many times they come to parties over-hungry because they're trying to restrict themselves and lose weight. So the standard definition of holiday eating becomes eating way too much.

 Fain. How about your approach to healthy eating: "Eating Competence." How would you describe that?

Satter. Rather than haranguing yourself about what you should and shouldn't be eating, you trust yourself to eat food you enjoy. No food is off limits. Which isn't to say you eat like there's no tomorrow. With eating competence, you work with your hunger, appetite, and satisfaction by eating meals and snacks, and by paying attention while you're eating. You trust yourself to eat as much as or as little as is right for you. It sounds wild and strange, but lots of research tells us being eating competent works. 

Fain. What does eating competence look like at a holiday party?

Satter. You take your plate and pick and choose what you find most appealing. You sit down and eat if you can. If not, do what you need to do to enjoy your food: stand in a quiet place, attach yourself to a group that will let you eat in peace. Go back for more as many times as you want and eat until you feel satisfied. That's the opposite of standard party eating, where a person doesn't take time to eat. The food may taste good momentarily, but, because they're not really paying attention, it's just absent-minded munching.

Fain. When I suggest what you're suggesting, new clients say: "If I let myself eat whatever I want, I'd really pack on the pounds." What do you tell clients who are worried about gaining weight?

Satter. Competent eaters don't gain weight over the holidays because they're accustomed to eating as much as they want of the foods they enjoy all year long. Holiday eating just gives more opportunities to eat good food. It's not a big deal to go home too full because you probably won't be too hungry the next day. Conversely, controlling eaters say: "I really overdid it! I have to cut down today." They deliberately under-eat, which sets them up for another bout of overdoing it. Come New Year's, they gotta get back on the diet. This vicious cycle creates a lot of misery, and, in the long run, weight gain. The strange thing is that most people believe that being hard on themselves is somehow better than being positive and sympathetic.

 Fain. Can you say more about New Year's resolutions?

Satter. People say: "I'm not going to eat all those delicious foods I love. I'm only going to eat fruits and vegetables and other 'good' foods.” Fruits and vegetables are wonderful, but if you're eating them as penance, you're not going to enjoy them. Then when you throw away control and eat what you really enjoy, you neglect them. Instead, think in terms of nutritional judo: go with your desire to eat as much as you want of foods you enjoy rather than fighting against it. Provide yourself with structure and pay attention while you eat, and you are well on your way to being eating competent. 

Fain. How do you suggest parents help their children become competent eaters?

Satter.  Follow the division of responsibility in feeding throughout children's growing-up years. Have meals and sit-down snacks, and regularly incorporate "forbidden foods." Don't set up deprivation with sugary, fatty foods. Deprivation does the same things to children as it does with adult dieters -- they restrict, then overdo it when they can. When you serve dessert, serve everyone a single portion. Let everyone eat it when they want -- before, during or after the meal. Periodically, at snack time, get out the milk and a whole plate of cookies, and let children eat as many as they want. If they haven't been allowed to eat cookies, they'll eat a lot of them at first. But if you do this repeatedly, the newness will wear off. The child will eat a cookie or two and be fully satisfied. It works.

Fain. I can hear parents worrying their kids will get fat. What would you say to those parents?

Satter. Restricting kids doesn't work. Forcing them to eat healthy foods doesn't work. What works is following the division of responsibility in feeding, trusting children to learn to eat the food you eat, and letting chldren grow up to get bodies that are right for them.  

For more about eating food you enjoy all year long (and for research backing up this advice), see Ellyn Satter's Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook.

- See more at: http://ellynsatterinstitute.org/fmf/fmf87.php#sthash.sf4IayZW.dpuf

An Intervention Using a 'Serious Videogame' prior to CBT for Bulimia Nervosa

One patient had reduced impulsivity, and binge eating was greatly reduced.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

Impulsivity is a common feature of bulimia nervosa (BN). The triad of behavioral disinhibition, impulsive decision-making, and emotional dysregulation often predicts relapse and dropout rates. A group in Spain recently used sessions with a "serious" videogame prior to cognitive behavioral therapy (CBT) to successfully treat a 34-year-old woman with BN (Frontiers in Psychology. 2015; July doi:10.3389/fpsyg.2015.00982).

Unlike conventional videogames, which are designed to entertain, serious videogames are designed to help improve skills, attitudes, and knowledge. For example, Playmancer™, a serious videogame, was developed to improve emotional regulation and impulsiveness in specific mental disorders and is currently being used by clinicians at the University Hospital of Bellvitage, Barcelona, Spain, to treat patients with eating disorders and addictions. 

A 34-year-old patient who binged and purged daily

Cristina Giner-Bartolomé and colleagues recently reported the case of a 34-year-old married mother of two with an earlier history of substance abuse problems until she was 21, when she received psychological treatment. With each pregnancy, the patient had steadily gained weight, until she her body mass index (BMI) was 34 kg/m2. During the 3 months before she entered the authors' study, she reported having daily binges followed by feelings of hopelessness and guilt, with episodes of vomiting. She also showed some classic traits of a Cluster B personality, with high levels of impulsivity, low tolerance for frustration, and poor emotional regulation. The woman also had occasional bouts of compulsive shopping. She had been treated with fluoxetine for the past 6 months.

At baseline, the authors obtained initial psychometric and neurophysiologic information, focusing on impulsivity levels measured with Conner's Continuous Performance II (CPT II), along with the Iowa Gambling Task (IGT), which evaluates decision-making, risk and reward and punishment. Eating and purging symptoms were recorded with food diaries kept by the patient. Other psychometric tests included the Eating Disorder Inventory 2 (ED-2) and the State-Trait Anxiety Inventory (STAI-S-T).

The second stage of the study involved 3 weeks of the use of the Playmancer videogame. Nine sessions of 26 minutes each were conducted and the 26 minutes were broken down as follows: 3 minutes of relaxing music, 20 minutes of the videogame, and 3 minutes of relaxing music. At the end of this stage the authors once more applied the CPTII.

One week after finishing the first intervention with the videogame, the authors once more measured the psychometric variables and levels of impulsivity (CPTII). A week after finishing the videogame intervention, the patient began group cognitive behavioral therapy (CBT). Three weeks after completing the CBT phase, the authors again applied the neuropsychological and psychometric tests. During each of the treatment stages the researchers recorded symptoms related to eating behavior, including the frequency of binge eating and vomiting.

At the end of treatment, the patient had lower levels of novelty-seeking, made fewer commission errors, had improved her ability for making decisions, and had fewer binge-eating episodes (the weekly average fell from 14.0 to 0.7). The authors noted that future studies might replicate their study with a larger sample of patients and add a control group. Although the patient was receiving an antidepressant, there had been no changes in her medication.

Intranasal Oxytocin Diminishes Food Intake, Improves Social Cognition among Bulimic Patients

The hormone had little or no effect on normal controls or patients with anorexia nervosa.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

Oxytocin (Greek for "quick birth") is a mammalian hormone that acts as a neurotransmitter in the brain. Because oxytocin impacts social behavior, appetite, anxiety, and stress, researchers believe oxytocin may also be involved in the pathophysiology of eating disorders.

There is some prior evidence for this. Intranasal administration of oxytocin leads to changes that may be important in AN; for example, an AN patient's attention to food and body image stimuli is reduced by oxytocin administration. Fewer studies have examined the oxytocin system among people with bulimia nervosa (BN), although some of the features of BN or binge eating disorder (BED) also hint of possible dysfunction in the oxytocin systems. For example, the hormone is an important peptide for body weight regulation. Animal studies have added information about the complex effects of oxytocin, particularly its ability to inhibit the appetite for sugars and carbohydrates. Similarly, in humans, when oxytocin was administered to a group of obese men, food intake was reduced.

A study of oxytocin's effect on appetite and emotions

A recent Korean study of 102 women (35 patients with AN, 34 with BN, and 33 healthy controls) tested the effects of a single dose of oxytocin on appetite and emotion recognition. At Seoul Paik Hospital, Seoul, South Korea, neuropsychiatrist Youl-Ri Kim and colleagues designed a double-blind, single-dose, placebo-controlled cross-over study to test the effects of the hormone (PLoS ONE. 10 (9)e13514.9. doi:10.1371/journal.pone.0137514).

Subjects and controls received a single dose (40 IU) of intranasal oxytocin or placebo, and then performed a computerized emotion recognition task, followed by an apple juice drink 90 minutes after the intranasal dose. All subjects' food intake was then recorded for 24 hours after the test. 

 Patients with eating disorders were given meal plans with fixed-size portions during the time of the experiment, to mitigate the drug's effect on calories consumed over the 24 hours before testing. Patients with AN did not have any direct support for eating during the 24 hours after the experiments on the inpatient ward, while patients with BN had meal plans focused on preventing binge eating and purging. The healthy controls were instructed to continue their regular diet during the 24 hours after the experiment.

Some effects were noted among patients with BN

The oxytocin dose produced no significant change in appetite among the healthy controls, but oxytocin modestly diminished 24-hour calorie intake in patients with BN. Oxytocin produced a small increase in emotion recognition sensitivity in healthy controls and in the patients with BN. In contrast, among the patients with AN, oxytocin had no effect on the patients' emotional recognition sensitivity or on food consumption. 

These results are interesting, and emphasize the complex effects of oxytocin on behavior, as well as the potential role of ED diagnosis (for symptoms) in determining response to oxytocin. One potential study limitation not noted by the authors is that subjects received a single dose; perhaps ongoing administration would have made effects last longer.

Tracing Triggers of Purging Among Anorexia Nervosa Patients

 multi-center study highlighted the impact of binge-eating episodes.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

In a recent study of adult women with anorexia nervosa, binge eating large amounts of food was the strongest predictor of purging, challenging the idea that loss of control is the most powerful aspect of distress in bulimia nervosa and binge-eating disorder. The researchers concluded that both loss of control and overeating appear to be important determinants of purging in patients with AN.

The multi-center study, headed by Andrea B. Goldschmidt, PhD, of the University of Chicago, studied behavioral, emotional, and situational factors linked to purging among 118 women with AN (Int J Eat Disord. 2015; 48:341). The women completed a two-week assessment protocol, including daily self- reports of eating disorder behaviors, mood, and stressful events. Prior to the study, the women spent two days practicing, to increase their familiarity with the protocol. Using a handheld computer, the women recorded their mood, stressful events, and behaviors after every binge-eating episode or AN behaviors such as binge eating and purging. 

The women responded to 6 daily semi-random prompts by investigators that occurred every 2 to 3 hours from 8 am to 10 pm. The women also were trained in standard definitions of events by the research staff and; they reported all body checking and purging behaviors. An abbreviated Positive And Negative Affect Schedule-Expanded (PANAS-X) form enabled participants to rate each reaction (such as nervousness or disgust) on a 5-point Likert-like scale, ranging from "Not at all" to "Extremely." Participants also recorded stressful events that occurred during the time from the last recording.

An unexpected finding

The researchers examined nearly 6,000 eating events from all the recordings, including 367 self-reported binge-eating episodes and 537 loss-of-control episodes, 152 overeating episodes, and 4,584 episodes that involved neither loss of control nor overeating (NE). Negative affect predicted purging after NE. A total of 112 purging episodes (34.5% of all purging episodes) were reported after NE.

The finding that self-reported binge eating most strongly predicted purging did not correlate with the authors' hypothesis that loss of control would be associated with purging. Prior studies have not included participants with AN, and thus the findings suggest that binge eating may differ among diagnostic eating disorder subgroups. The patient's subjective perception that she has consumed an "excessive" amount of food may be particularly important in AN, according to the authors.

A Spotlight on Weight and Disordered Eating Patterns

In a large Norwegian study, weight problems and disordered eating were not distinct from one another.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

While eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder affect from 5% to 10% of the population, an even larger group has disordered eating patterns or subthreshold eating disorders. A general population study of 27,252 Norwegian women 19 to 99 years of age recently revealed a wealth of information, including a 12% prevalence of disordered eating, especially in women with weight problems (BMJ Open 2015; 5:e008125. doi:10.1136/bmjopen-2015-008125).

Trine Eik-Nes, MD and colleagues at the Norwegian University of Science and Technology, Trøndheim, and Levanger Hospital, Levanger, Norway, recently reported the findings from their cross-sectional community study. The information about disordered eating patterns emerged as part of the third survey from the Nord-Trøndelag Health Study (HUNT3). The HUNT survey provides information from the total population, 14 years of age and older, in Nord-Trøndelag County, Norway. The entire county is invited to participate and at the last survey 93,860 women were invited and 52% agreed to join the study. For young adults, the researchers used a shortened version of the Eating Attitudes Test (they termed it the EAT-8) that involved two factors: 'oral control' and 'bulimia and food preoccupation.'

Results: a majority were overweight or obese

The mean body mass index (BMI, kg/m2) was 26.9 for the more than 27,000 women (mean age: 53 years) who participated. Of all women in the sample, 61.1% were either overweight or obese, and 32% were in the obese category. Two-hundred and forty-two women were in the underweight category, and 966 women had a BMI <20. BMI increased with age, and obesity (BMI ≥30 kg/m2) and extreme obesity (BMI ≥35 kg/m2) were most prevalent in women 60 to 70 years of age.

Among women younger than 30 years of age, 11.8% reported disordered eating. Weight problems were associated with disordered eating overall and with oral control and bulimia and food preoccupation. Underweight women had almost 5 times higher odds of high oral control than did normal-weight women, while women in the obese category were more likely than normal-weight women to show symptoms of bulimia and food preoccupation. As for dieting, 58.8% of the entire group reported being dissatisfied with their current weight, and women dissatisfied with their weight were 7 times more likely to be dieting than not. 

More than half of the women in the study reported dieting and treated dieting as a normal practice; dieting was largely dependent on weight dissatisfaction and not on BMI. In fact, the authors noted that a sizeable number of women were dissatisfied with their weight even when their BMIs were within a normal healthy range for their weight.

Disordered eating was not associated with younger age among women 19 to 30 and the authors found no association between age and weight dissatisfaction. Dr. Eik-Nes and colleagues' overall conclusion was that weight problems and disordered eating were not distinct from one another. In addition, they concluded that prevention and treatment for disordered eating and weight control among women should include an assessment of body image as well.

Is the Brain's Microstructure Important in AN?

One study examined the role of the subcalloseal cingulate cortex. 

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

Increasingly researchers are exploring the brain to find clues to the development of anorexia nervosa (AN). Within the brain the subcallosal cingulate cortex (SCC) regulates affect, and thus may play a role in the pathophysiology of AN. 

Recently developed magnetic resonance imaging techniques such as diffusion tensor imaging allow researchers to assess whether white matter connections are intact or disrupted. A group of neuroscientists and psychologists at the University of Toronto recently used diffusion magnetic resonance imaging (dMRI) and multi-tensor tractography to compare the anatomic connections and microcircuits among 8 women with treatment-resistant AN and 8 sex- and age-marched healthy controls. The women with AN were also clinically assessed before and after deep brain stimulation (Brain Stimulation. 2015; 8:758). All subjects underwent implantation of bilateral electrodes in the SCC followed by MRI.

Different patterns in healthy subjects and patients

As the authors reported, subcalloseal connectivity was different between AN patients and controls. The most marked differences were increased connectivity to the ipsilateral parietal cortex and decreased connectivity to the thalamus bilaterally in the AN patients. The scans also showed many equally connected regions in both groups of subjects. 

The main relationships between clinical affective measures and dMRI were seen in the left fornix crus, inferior frontal occipital fascius (IFO), and right internal capsule, or the anterior limb of the internal capsule, or ALIC, among the AN patients. The abnormalities were consistent with a central role for dysfunctional affective processing and broad clinical changes, particularly changes in processing of affective stimuli, self-perception, and interoception, according to Dr. Dave J. Hayes and colleagues.

The findings should be viewed as preliminary and the sample was small — but among those with AN differences in connectivity and intact circuits were seen. Furthermore, dMRI metrics predicted a deep brain stimulation response. The authors are correct in noting that such preliminary findings may point the way toward the development of sophisticated predictors of treatment response.

Gauging Distress in an Adult AN Patient's Partner

Distress was lowest when both partners agreed on the need for change.

Reprinted from Eating Disorders Review
November/December Volume 26, Number 6
©2015 IAEDP

Being in a romantic relationship with a patient with anorexia nervosa (AN) can be challenging. And, for patients with AN, their romantic partners may be their main interpersonal relationship. Such relationships can endure significant amounts of strain, but it is still unclear what influence a partner's level of distress has upon the partner with an eating disorder.

In one of the first empirical studies to use data from direct observations of adult female patients with AN and their intimate partners, University of North Carolina researchers found that the partners experienced the least distress when their attempts to get the patient to change harmful behaviors fit well with the patient's perception of the negative consequences of the illness and her motivation to change the behaviors (Int J Eat Disord. 2015; 48:67). Partners had the least amount of distress when they tried to promote changes in AN behaviors and also attempted to show understanding of the patient's experience.

Melanie S. Fischer and her fellow researchers in the Departments of Psychology and Psychiatry at the University of North Carolina at Chapel Hill examined cross-sectional relationships between self-reports of patients' perceived negative consequences of AN, their partners' level of caregiver distress, negative affect, satisfaction with the relationship, and use of promoting change and acceptance/validation. Sixteen adult patient-partner pairs were studied as they started a couple-based intervention for AN. The couples had to have been in a committed relationship and living together for at least one year. In addition, the patient had to have a body mass index greater than 16 kg/m2. 

Working as a team lessens distress

When both partners worked as a team to promote change and work toward recovery, partner distress was less. Those partners who displayed higher acceptance/validation reported less negative affect. It seems logical that this would be well-received by patients and assist in coping with illness strains. However, the researchers also noted that if partners have negative affect, it might be difficult for them to show understanding and to validate the patient's struggles with AN.

The authors are correct in thinking of their findings as "exploratory." It was a single study and the sample was small. Still, this is potentially highly valuable work as it expands our knowledge relative to treating adults with AN, an area of greater need.